1. Right iliac fossa pain CPC Dr Tim Bracey SpR in Histopathology 7/5/08

2. RIF pain CPC Outline Introduction Introduction Definitions and anatomy Definitions and anatomy Causes of RIF pain Causes of RIF pain 3 case studies 3 case studies Focus on clinical presentation and differential diagnosis Focus on clinical presentation and differential diagnosis Discussion Discussion

3. What is the iliac fossa? Iliac bone is shallow concave surface covered by ilacus and psoas muscle Iliac bone is shallow concave surface covered by ilacus and psoas muscle Peritoneal organs sit in this shallow cup Peritoneal organs sit in this shallow cup Generally refers to the right lower quadrant Generally refers to the right lower quadrant

4. Introduction Acute abdominal pain is defined as previously undiagnosed pain <72 hours duration Acute abdominal pain is defined as previously undiagnosed pain <72 hours duration Accounts for 2% of all hosp admissions Accounts for 2% of all hosp admissions RIF pain accounts for at least half of these! RIF pain accounts for at least half of these! Primary focus clinically is ruling out a cause that requires urgent surgery Primary focus clinically is ruling out a cause that requires urgent surgery

5. What are the causes of right iliac fossa pain! Intestinal Intestinal Appendicitis! Appendicitis! Caecal or Meckels diverticulitis Caecal or Meckels diverticulitis Ileocaecal Crohn’s disease Ileocaecal Crohn’s disease Intestinal neoplasm Intestinal neoplasm Mesenteric adenitis Mesenteric adenitis Gynaecological Gynaecological Ectopic (tubal) pregnancy Ectopic (tubal) pregnancy Torted/ruptured ovarian cyst Torted/ruptured ovarian cyst Urological system Urological system Ureteric colic Ureteric colic Torted testis Torted testis

6. Case study 1 14 year old girl presents with 24 hour hx right lower quadrant abdominal pain 14 year old girl presents with 24 hour hx right lower quadrant abdominal pain No PMH or surgery No PMH or surgery What points in the history would you concentrate on? What points in the history would you concentrate on? Pain (remember SOCRATES) Pain (remember SOCRATES) Specific site, onset, character, radiation, associated symptoms (nausea, vomiting, diarrohea, anorexia, peritonism, timing, had before?) Specific site, onset, character, radiation, associated symptoms (nausea, vomiting, diarrohea, anorexia, peritonism, timing, had before?) Any gynaecological / urinary /systemic sx Any gynaecological / urinary /systemic sx Pregnant? Timing of periods (Mittelschmirtz), discharge, frequency, dysuria, fever etc. Pregnant? Timing of periods (Mittelschmirtz), discharge, frequency, dysuria, fever etc. Recent sore throat /URTI? Why ask this? Recent sore throat /URTI? Why ask this?

7. Case study 1 On further questioning, pain started gradually, centrally, cramping but constant background, but has now localised to the RIF On further questioning, pain started gradually, centrally, cramping but constant background, but has now localised to the RIF Why does pain in appendicitis move from a vague central to a specific point in the RIF? Why does pain in appendicitis move from a vague central to a specific point in the RIF? Initial pain is carried in visceral nerves localising to the midgut whereas later inflammation causes pain carried from somatic nerves in the parietal peritoneum Initial pain is carried in visceral nerves localising to the midgut whereas later inflammation causes pain carried from somatic nerves in the parietal peritoneum She vomited once, and has been off her food for 12 hours, bowels normal, some urine frequency She vomited once, and has been off her food for 12 hours, bowels normal, some urine frequency LMP 2/52 ago, no other gynae sx, no chance of pregnancy LMP 2/52 ago, no other gynae sx, no chance of pregnancy

8. Case study 1 What would you do next? What would you do next? Examination Examination T38 degrees T38 degrees Foetor Foetor No JACCOL No JACCOL Chest clear, RR 16, HS 1+2+0, peripheral pulses Chest clear, RR 16, HS 1+2+0, peripheral pulses What signs on abdo examination important? What signs on abdo examination important? Localised peritonism over McBurneys point Localised peritonism over McBurneys point What are the surface markings of McBurneys point? What are the surface markings of McBurneys point?

9. Case 1 - Mc Burney’s point Maximal tenderness here in this patient

10. What other clinical signs may be elicited in appendicitis? Rovsing’s sign Rovsing’s sign Pain in RIF on palpation of LIF Pain in RIF on palpation of LIF Obturator sign Obturator sign RIF pain with internal rotation of flexed hip RIF pain with internal rotation of flexed hip Psoas sign Psoas sign RIF pain on hyperextension of R hip RIF pain on hyperextension of R hip Positive “cough sign” Positive “cough sign” Adnexal tenderness on vaginal/PR exam Adnexal tenderness on vaginal/PR exam

11. Case 1 - investigations What investigations are necessary in this case? What investigations are necessary in this case? Bedside – urine dip, urine beta-HCG Bedside – urine dip, urine beta-HCG Bloods – FBC, U+E, CRP?, group and save? (bloods usually done for older patients or atypical history / exam findings) Bloods – FBC, U+E, CRP?, group and save? (bloods usually done for older patients or atypical history / exam findings) Imaging – pelvic USS Imaging – pelvic USS Invasive – Laparoscopy Invasive – Laparoscopy NB. Laparoscopic appendicectomy is rarely carried out on males with RIF pain NB. Laparoscopic appendicectomy is rarely carried out on males with RIF pain

12. What points should be explained when consenting the patient / family? What are the possible complications from appendicectomy? Nil by mouth, fluids, antibiotics (allergies?) Nil by mouth, fluids, antibiotics (allergies?) General anaesthetic General anaesthetic 3 small wounds 3 small wounds Appendix will be removed even if normal! Appendix will be removed even if normal! Wound infection Wound infection Bleeding / bruising Bleeding / bruising Incisional hernia Incisional hernia

13. Case 1 - laparoscopy The appendix tip was inflamed and adherent to the dome of the bladder. A pus swab was sent to microbiology The appendix tip was inflamed and adherent to the dome of the bladder. A pus swab was sent to microbiology The tubes and ovaries were normal The tubes and ovaries were normal Inflamed appendix

14. Case 1 - specimen The appendix tip shows surface purulent (pus) exudate and serosal (peritoneal) congestion The appendix tip shows surface purulent (pus) exudate and serosal (peritoneal) congestion There is no evidence of perforation There is no evidence of perforation Yellow exudate

15. Case 1 - histology Mucosal ulceration and acute inflammation (neutrophils) Mucosal ulceration and acute inflammation (neutrophils) Inflammation extends through the full thickness of the appendix wall to serosal surface (peritonitis) Inflammation extends through the full thickness of the appendix wall to serosal surface (peritonitis)

16. Why does appendicitis sometimes present with symptoms outside the right iliac fossa? Why might our patient have had urinary symptoms? Why might our patient have had urinary symptoms?

17. What causes appendicitis? Obstruction of appendiceal lumen by… Obstruction of appendiceal lumen by… Lymphoid follicles faecalith Worms Tongue studs!!

18. Case 2 - history 21 year old female 21 year old female 7 days gradual onset intermittent RIF pain with associated fever 7 days gradual onset intermittent RIF pain with associated fever Cramping 7/10 max, no radiation, vomiting x2, 12hrs anorexia, loose motions Cramping 7/10 max, no radiation, vomiting x2, 12hrs anorexia, loose motions First episode of these symptoms First episode of these symptoms No urinary symptoms No urinary symptoms On direct questioning admits to several recent unprotected sexual partners but is on OCP On direct questioning admits to several recent unprotected sexual partners but is on OCP

19. Case 2 - examination Afebrile T36.8 Afebrile T36.8 No jaundice No jaundice Finger clubbing present Finger clubbing present CVS and resp unremarkable CVS and resp unremarkable Abdo soft with no peritonitis Abdo soft with no peritonitis Tender in RIF, slight fullness Tender in RIF, slight fullness PV NAD other than R adnexal tenderness PV NAD other than R adnexal tenderness PR empty rectum PR empty rectum What investigations would you request? What investigations would you request?

20. Case 2 - investigations What investigations are necessary in this case? What investigations are necessary in this case? Bedside – urine dip and MCS, urine beta- HCG, high vaginal swabs Bedside – urine dip and MCS, urine beta- HCG, high vaginal swabs Bloods – FBC, U+E, CRP Bloods – FBC, U+E, CRP Imaging – TV / pelvic USS Imaging – TV / pelvic USS Invasive – Laparoscopy Invasive – Laparoscopy NB. Laparoscopic appendicectomy is rarely carried out on males with RIF pain NB. Laparoscopic appendicectomy is rarely carried out on males with RIF pain

21. TV USS revealed 17mm ovarian cyst, no evidence of rupture Appendix grossly normal Transabdominal USS showed a dilated thickened small bowel loop (terminal ileum)

22. What investigation could be used to visualise the thickened small bowel loop?

23. Abnormal segment of terminal ileum Case 2 – contrast follow through

24. =========================================================== REPORT Radiological Diagnosis: Reason for Exam: Radiological Diagnosis Code: Radiological Report : Clinical History : Right iliac fossa pain, Barium Small Bowel Meal/Follow Through : Examination performed by Christine Searle, Senior Radiographer. Contrast has passed through to large bowel by the 1 hour 15 minute film. The jejunal and proximal ileum appears unremarkable but there is an eight to 10 cm segment of abnormal terminal ileum. There is quite marked loop separation in the iliac fossa suggesting quite marked fatty proliferation and inflammatory mass. The abnormality is also involving the caecal pole. There is also is a suggestion of a fistula tract between small bowel loops. The appearances are consistent with ………………………. Case 2 – contrast follow-through

25. Case 2 - “macro” small bowel resection Dilated thin-walled Bowel proximally Dilated thin-walled Bowel proximally “fat wrapping” Thickened muscle wall Stricture segment

26. What diagnosis do you suspect by macro findings shown above? Terminal ileum thickened bowel loop Terminal ileum thickened bowel loop Thick walled stenotic stricture Thick walled stenotic stricture Patchy disease process, no evidence of inflammation in the colon Patchy disease process, no evidence of inflammation in the colon ………Crohns ileitis ………Crohns ileitis

27. Case 2 - “micro” small bowel resection Full thickness inflammation Deep “fissuring” ulcer Crohns “rosary” of lymphoid follicles X2 mag Deep “fissuring” ulcer X10 mag

28. Crohns disease Chronic episodic inflammatory bowel disease Chronic episodic inflammatory bowel disease Can affect any part of GI tract Can affect any part of GI tract Patchy distribution Patchy distribution Full thickness inflammation Full thickness inflammation Strictures, fissures, fistulas Strictures, fissures, fistulas Granulomatous inflammation Granulomatous inflammation Most commonly affects terminal ileum Most commonly affects terminal ileum Does Ulcerative colitis present with RIF pain? Does Ulcerative colitis present with RIF pain?

29. Case 3 - History 30 year old female 30 year old female History of cone biopsy for CIN3 History of cone biopsy for CIN3 24 hours lower abdominal pain 24 hours lower abdominal pain Localised to RIF last 6 hours Localised to RIF last 6 hours Difficulty walking particularly moving right leg Difficulty walking particularly moving right leg Nausea and vomiting, loose stool today Nausea and vomiting, loose stool today LMP 8/52 LMP 8/52 Your differential diagnosis? Your differential diagnosis?

30. Case 3 - Examination Alert and oriented. Looks pale Alert and oriented. Looks pale T37.5 T37.5 P105 BP 95/50 P105 BP 95/50 RR20 sats 99% on air RR20 sats 99% on air Abdomen generalised tenderness but max tender in RIF over Mc Burney’s pt Abdomen generalised tenderness but max tender in RIF over Mc Burney’s pt Rovsing’s +ve, Psoas sign +ve Rovsing’s +ve, Psoas sign +ve What would you do next? What would you do next?

31. Case 3 - investigations None needed None needed Patient needs resusitation before theatre Patient needs resusitation before theatre Bloods Bloods Hb 9.5, WCC 15, PLT 405 Hb 9.5, WCC 15, PLT 405 Clotting normal Clotting normal U+E consistent with mild dehydration U+E consistent with mild dehydration Urine dip NAD Urine dip NAD Pregnancy test positive! Pregnancy test positive!

32. Case 3 - laparoscopy Peritonitis, 500mls blood in peritoneum Peritonitis, 500mls blood in peritoneum Right tubal pregnancy! Appendix normal Right tubal pregnancy! Appendix normal

33. Case 3 – ectopic pregnancy Ectopic pregnancy should always be considered in any case of acute abdominal pain Ectopic pregnancy should always be considered in any case of acute abdominal pain Can implant anywhere in peritoneum but most commonly tubal Can implant anywhere in peritoneum but most commonly tubal Commonly resolve spontaneously but can present with peritonitis and life threatening bleeding Commonly resolve spontaneously but can present with peritonitis and life threatening bleeding

34. Summary RIF pain is a commonly encountered clinical presentation RIF pain is a commonly encountered clinical presentation Most important to rule out appendicitis and other conditions that need urgent surgery Most important to rule out appendicitis and other conditions that need urgent surgery 3 common case studies 3 common case studies

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